Have you ever heard about medical gap cover or asked what does medical gap cover include?
If not, now would be a good time. Especially if a friend told you about having to pay a huge, unexpected medical bill that their medical aid never paid.
Perhaps you are concerned because you wonder whether or not your medical aid will cover a private hospital stay.
Maybe you have a pre-existing condition and are concerned that you don’t qualify for gap cover.
What does Medical gap Cover include?
Let’s put your mind at rest. Gap cover is not something that everyone understands so let’s go through what it is.
Your medical aid will only pay an agreed rate for medical care. If you have medical bills that exceed this rate, you are going to be responsible for the excess.
And it’s standard medical practice that these limits are in place. It makes sense – medical aid firms only have a certain amount of funds. In order to cover all members as they should, they must limit their cover.
In a perfect world, this would be more than enough. But this is not a perfect world.
Most doctors and specialists feel that the rates offered by medical aid firms are too low. They, therefore, charge their rate which could be as much as a 500% markup on these charges.
Gap Cover and What it’s For
That is why it makes sense to look into getting gap cover. Gap cover does not pay the portion covered by the medical aid, it pays the excess.
Gap cover is only paid out after your medical aid pays it’s portion of the bill first. So, you will have to provide proof of what the medical aid paid.
What Gap Cover Includes
This will differ from policy to policy. In general, though, the bigger medical expenses like hospital stays are covered.
You may be able to claim for hospital admission fees, deductibles and co-payments. If, however, any of these excesses are as a result of you breaking your medical aid’s rules, you won’t be covered.
Say, for example, that your medical aid charges a standard co-payment whenever you go to a specialist. This should be covered by gap cover.
If, however, they charge you a penalty for not getting pre-authorisation, you won’t be covered.
Ordinarily, only essential medical procedures are covered. So, if you go in for a breast reduction, for example, the cover won’t apply.
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All info was correct at time of publishing